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RESEARCH REPORT

Mental and Physical Health Behaviors of Doctor of Physical Therapy Students

Ellison, Jennifer PT, PhD; Mitchell, Katy PT, PhD; Bogardus, Jennifer PT, PhD; Hammerle, Kristi SPT; Manara, Carly SPT; Gleeson, Peggy PT, PhD

Author Information
Journal of Physical Therapy Education: September 2020 - Volume 34 - Issue 3 - p 227-233
doi: 10.1097/JTE.0000000000000141

Abstract

BACKGROUND AND PURPOSE

The 2016 American College Health Association–National College Health Assessment (ACHA-NCHA) Survey of university students in the United States indicated that an increasing number of both undergraduate and graduate students reported poorer physical and mental health behaviors compared with similar surveys in the previous decade.1 The undergraduate report (N = 27,787 surveys from 51 universities) indicated that 39% of students felt depression that limited function during the previous year, 62% felt overwhelming anxiety, 11% had considered suicide, and 2% had attempted suicide. The graduate student results (N = 5,099 surveys from 34 schools) were only slightly better. In 2018, Evans et al2 reported that graduate student respondents from 26 countries were 6 times more likely to experience depression and anxiety when compared with the general population. Mental health disorders, such as depression and anxiety, were reported to be high in students who are pursuing a graduate degree in health professions, specifically those studying medicine, dentistry, nursing, physical therapy, communication science disorders, and physician assistant studies.3-11 These studies report findings from the United States and a number of other countries. Most studies that investigate physical therapy students' health have been from countries other than the United States. Over half of undergraduate physical therapy students in Pakistan had a considerable amount of depression, anxiety, and stress.11 A second study from Pakistan reported that of 380 Doctor of Physical Therapy (DPT) students, 19.6% reported mild stress, 38.2% reported moderate stress, and 40.1% reported severe stress.12 Physical therapy students in the Netherlands and Sweden reported moderate levels of stress with stressors being physiological, emotional, behavioral, and cognitive in nature.13 One-quarter of students attending a physical therapy program in Ireland scored above the General Health Questionnaire-12 threshold for probable psychological morbidity with the greatest sources of stress being academic and personal.14 Up to 71.2% of South African PT students in the clinical training part of their program were experiencing high levels of psychological distress, with less than 6% of them receiving any form of professional help.15 Female Hungarian PT students often have higher stress reactions than their male counterparts16 and are more affected by a lack of a social support system.17 In the United States, students in their first year of a PT program reported more stress than in the subsequent years.10 Overall, compared with age- and gender-matched peers, DPT students in one US school had higher levels of stress and anxiety.18

Academic stress is reported as a top stressor for PT students, but other factors could play a role in PT students' mental health.8 Factors such as unhealthy lifestyle habits, academic difficulty, and musculoskeletal pain have been shown to correlate with mental health symptoms in undergraduate students pursuing an allied health professions degree.19 Mazurek Melnyk et al20 reported that health science graduate students are aware of the importance of physical activity, healthy eating, and getting adequate sleep but are struggling to maintain these activities in their own lives, which may contribute to the increase in stress, anxiety, and depression. In undergraduate students, poor sleep quality was correlated with higher levels of anxiety and/or depressive symptoms and there was an inverse relationship between physical activity level and anxiety.21 Graduate students who are highly active have lower levels of anxiety and depression when compared with graduate students who are not active.22 Furthermore, health professional graduate students who have overall healthy lifestyle behaviors and beliefs demonstrate an inverse relationship with depression and anxiety.20

The literature clearly identifies that physical and mental health challenges are prevalent in the undergraduate prospective student population and in professional graduate programs including physical therapy students in the United States and numerous other countries. The purposes of this study were to assess the DPT students' depression, anxiety, and stress levels using the 21-item Depression, Anxiety, and Stress Scale (DASS-21)23 to investigate how mental and physical behaviors correlate with DPT students' mental health and to identify the coping strategies of DPT students to guide the intervention strategies of PT programs.

METHODS

Students who were enrolled in the first, second, or third year of our DPT program in the spring of 2018 (N = 136) received an email invitation to complete the Student Health Survey. A 49-item survey was developed by the 3 DPT faculty authors that included demographic information, physical health behaviors such as exercise type and frequency, nutritional habits, sleep behavior, alcohol use, and mental health behaviors including personal and family history, use of resources, and the effects of an environmental disaster during their DPT program. The DASS-21 was embedded in the survey and the 3 open-ended questions about the top 3 stressors of PT school, top 3 strategies for stress relief, and an opportunity to list other factors that were not addressed in the survey. The DASS-21 is a set of 3 self-report scales designed to measure the negative emotional states of depression, anxiety, and stress with higher scores indicating poorer mental health status. The tool was developed by researchers at the Psychology Foundation of Australia, has high internal consistency, and is in the public domain for use by researchers and clinicians.23 The DASS-21 was chosen for this study because it assesses 3 constructs, is relatively short compared to other tools, is free to administer, and has been used in previous research in graduate students. Our survey is included as Appendix A (Supplemental Digital Content 1, http://links.lww.com/JOPTE/A81). All participants provided consent at the beginning of the online survey according to the guidelines approved by the Texas Woman's University Institutional Review Board.

Statistical analysis was completed using SPSS version 25. Descriptive statistics were examined for each question. Depression, anxiety, and stress subscores were calculated from the responses to the embedded DASS-21 questionnaire. Correlational analyses assessed relationships among the DASS-21 scores and gender, physical activity, sleep, and relationship status. Three 1 × 3 analyses of variances were used to assess the subscores by year in the DPT program. The alpha level was set at 0.05 for all analyses. The quantitative responses for the top 3 stressors and the top 3 coping strategies were grouped by themes and counted.

RESULTS

Fifty-nine DPT students responded (43%): 27 second semester students, 17 fifth semester students, and 15 eighth semester students. Participants included 48 women and 11 men with a mean age of 25.48 years (R = 23–36 years). Ethnicity self-reports included 32 Caucasian, 11 Hispanic, 4 African American, 3 Asian/Pacific Islander, and 9 students checked other or more than one ethnicity. Relational data identified that 19 were single, 27 were in a dating relationship, and 13 had a spouse or partner. Six lived alone; 46 lived with a roommate, spouse, or partner; and 7 lived with parents or siblings.

Physical health questions revealed that the DPT students reported sleeping an average of 6.58 hours per night (R = 5–9, SD = .93). Exercise participation in aerobic exercise, strengthening exercise, and relaxation is reported in Table 1. Additional physical activities reported included ballet, soccer, martial arts, and walking to school. Only 52.5% reported aerobic activity 3 or more times per week. Fewer students reported performing strengthening exercises, and only half reported using relaxation exercise more than occasionally. Reports of nutritional habits are summarized in Table 2. On average, these DPT students met the governmental requirements that were likely taught as a food pyramid when these students were adolescents24 with a number of students who were not meeting the minimum requirements for the various food groups and others who were overindulging. Undereating and overeating can be faulty coping strategies for mental health issues that can also affect physical health. Alcohol intake is reported in Table 3. According to the Dietary Guidelines for Americans,25 moderate alcohol consumption is defined as 1 drink per day for women and 2 drinks per day for men. No men reported exceeding the 2 drinks per day recommendation. Four percent of the women who participated in the survey exceeded the recommended number of drinks on a weekday, and 20% of the women reported drinking more than 2 drinks on weekend days.

Table 1. - Exercise Participation: Number of Students Reporting Type and Frequency
Type of Exercise Days/Week
5–7 3–4 1–2 0
Aerobic 8 23 24 3
Strengthening 4 13 30 11
Relaxation 2 4 12 29 (12 occasionally)

Table 2. - Nutritional Data: Typical Number of Servings per Day
Food Group Mean Range Recommended23
Grains: bread, cereal, rice, pasta 4.12 2–10 6–11
Vegetables 3.34 1–9 3–5
Fruit 3.08 1–9 2–4
Proteins: meat, poultry, fish, beans, eggs, nuts 3.2 1–10 2–3
Dairy: milk, yogurt, cheese 3.03 1–11 2–3

Table 3. - Alcohol Intake: Typical Number of Drinks per Weekday and per Weekend day
0 Drinks 1 Drink 2 Drinks 3 Drinks 4 Drinks 5 or More
Weekday 47 (9 M, 38 F) 8 (1 M, 7 F) 3 (1 M, 2 F) 0 0 0
Weekend day 18 (3 M, 15 F) 15 (2 M, 13 F) 15 (6 M, 9 F) 5 (0 M, 5 F) 4 (0 M, 4 F) 1 (1F)
Abbreviations: F = female; M = Males.

Table 4 highlights that most students had normal DASS-21 scores for stress (66%), anxiety (64%), and depression (73%). However, only 46% had normal ranges for all 3 scales and a concerning number of students scored moderate and severe levels of stress (19%), anxiety (25%), and depression (12%). One student had an extremely severe depression score and 4 students (7%) reported previous suicide ideation. University counseling was used by 29% of respondents and private counseling by 8% (Table 5). A major hurricane with significant flooding occurred in the days preceding the start of the previous semester. Although only 8 students reported damage to their homes and 6 reported loss of personal possessions during the natural disaster, 44% of the students reported personal stress related to the natural disaster (Table 6). Thirty-nine percent reported that their relationship with a faculty advisor was important/extremely important regarding their overall well-being while in the DPT program (Fig 1). Forty-nine percent reported that the role of spirituality in their life is very important (Fig 2). History of mental health questions (Table 7) revealed family histories of anxiety (36%), depression (41%), other mental health disorders (24%), and eating disorders (12%). Personal history questions revealed that 29% of the DPT students have experienced anxiety, 25% depression, 3% other mental health disorders, and 7% have dealt with eating disorders.

Table 4. - DASS-21 Subscales: Number of Students by Subscale and Severity
Score Severity Stress Anxiety Depression
Normal 39 38 43
Mild 9 6 8
Moderate 7 6 7
Severe 4 9 0
Extremely severe 0 0 1

Table 5. - Number of Students That Utilized Resources as Undergraduate and Graduate Students
Resources Undergraduate DPT Program
University counseling 10 17
Private counseling 4 5
Psychiatrist 2 3
Medication 6 8
Meditation/relaxation/exercise 35 35
Other 4 5
aStudents could respond to more than 1 item.

Table 6. - Effects of the Natural Disaster
Effect No. of Students
Loss of personal items 6
Home damage 8
Financial stress 10
School stress 23
Personal stress 26
None of the above 24
aStudents could respond to more than 1 item.

Figure 1.
Figure 1.:
Importance of Relationship With Faculty Advisor Regarding the Overall Well-Being in the Doctor of Physical Therapy Program
Figure 2.
Figure 2.:
Role of Spirituality
Table 7. - Number of Students Reporting History of Mental Illness
Type of Mental Illness Family History Personal History
Anxiety 21 17
Depression 24 15
Suicide or suicide ideation 3 4
Obsessive compulsive disorder 2 1
Bipolar disorder 5 0
Schizophrenia 2 0
Eating disorder 7 4
Other 5 1
aStudents could respond to more than 1 item.

Statistical analyses revealed no correlation between the DASS-21 scores and the gender or relationship status. All subscores of the DASS-21 were inversely correlated with hours of sleep: stress (r = −0.317, P = .014), anxiety (r = −.467, P ≤ .005), and depression (r = −0.310, P = .017). Frequencies of aerobic exercises and strengthening and relaxation techniques were not correlated with anxiety or stress subscores; however, depression subscores were associated with lower frequency of aerobic (r = −0.335, P = .01) and strengthening exercises (r = −0.259, P = .049). There was no significant difference between first-, second-, or third-year students in the subscores of stress (P = .189), anxiety (P = .095), or depression (P = .149) (Table 8).

Table 8. - Average Stress, Anxiety and Depression by Year in the DPT Program
DASS-21 Sub-Score Year in Program Average SD Minimum Maximum
Stress score: P = .189 Year 1 14.07 6.433 2 28
Year 2 9.88 7.193 0 20
Year 3 10.80 10.658 0 32
Anxiety score: P = .095 Year 1 8.52 8.313 0 28
Year 2 5.29 6.669 0 26
Year 3 3.73 4.832 0 16
Depression score: P = .149 Year 1 7.85 4.400 0 16
Year 2 5.65 6.214 0 20
Year 3 4.40 6.936 0 28

When asked to list the top 3 stressors of being in the DPT program, most answers related to coursework (workload, schedule, difficult material, number of assignments, and grades), followed by study concerns (amount of time required/time management). Additional stressors included life balance, financial concerns, and personal and professional expectations.

Responses regarding the top 3 strategies used for stress relief largely reflected healthy strategies of exercise (66%) and time with friends or family (63%) with fewer participants reporting time management, spirituality, sleeping, outdoor or leisure activities, counseling, or meditation. Fewer unhealthy strategies were reported; however, the use of alcohol as a strategy for stress relief was reported by 14%.

DISCUSSION AND CONCLUSIONS

Incidence

Most DPT students in this study had normal subscores on the DASS-21; however, slightly less than half of them had normal scores in all 3 realms of stress, anxiety, and depression. A concerning number of students had moderate, severe, or extremely severe scores in one or more realms, and 7% had previous suicide ideation. The American College Health Association–National College Health Assessment data reported in 2016 indicated that high numbers of graduate and professional students suffer from a variety of mental health conditions.1 The ACHA-NCHA survey questions regarding the previous 12 months indicated the prevalence of overwhelming anxiety (55%), overwhelming anger (33%), depression that limited function (33%), and thoughts of suicide (6%). Although the DPT students in the present study had lower incidence of anxiety and depression, the percentage of suicide ideation was similar. Previous studies suggest that graduate students often struggle to manage academic course load with personal and social responsibilities which may result in a dramatic increase in stress.26,27 Prolonged levels of high stress can lead to an increased risk for developing mental health disorders such as anxiety and depression.26,27 Kernan et al28 reported that graduate health science students perceive mental health concerns such as stress, anxiety, and depression to be one of the top factors negatively affecting their academic success.

Online survey responses from 14,175 college students from 26 campuses nationwide identified the following prevalence of mental health issues: 17.3% for depression, 4.1% for panic disorder, 7.0% for generalized anxiety, 6.3% for suicidal ideation, and 15.3% for nonsuicidal self-injury.29 Mental health problems were significantly associated with sex, race/ethnicity, religiosity, relationship status, living on campus, and financial situation.29 The DPT students in the current study had lower incidences of moderate to high anxiety and depression compared with other graduate student studies; however, a similar incidence of suicide ideation is consistent across studies. According to Hunt and Eisenberg,30 risk factors for mental health disorders include gender, socioeconomic factors, and social and relational issues. Male undergraduates are at a higher risk for suicide, but female students are more likely to screen positive for major depression and anxiety disorders. In this study, male students did not demonstrate higher DASS-21 scores or suicidal ideation than female students. This finding may be due to the fact that the gender gap noted in the previous studies represented a more global scale of depression over time and that depression tends to recur more often in women than in men.31 Previous studies indicate that students from lower socioeconomic backgrounds, veterans, and international students are all at a higher risk for depressive and anxiety symptoms.32-34 The DPT programs seek to admit students from a variety of socioeconomic and cultural backgrounds; however, the programs may not anticipate the mental health challenges of a diverse student population or offer preventative education and interventions when stress, anxiety, and depression affect the students' health and success.

Sources of Stress

Students' responses in the present study regarding the sources of stress are consistent with previous reports that cite high academic workload as the primary stressor along with examinations, grades, and assignments.8-10,12,35,36 The substantial time demands of the DPT programs result in less time for personal and social responsibilities.8,9 The most commonly reported stressors during the clinical training part of a DPT program are death of patients, academic pressure, and tension during interaction with the clinical instructor and academic staff.12 Twenty-five percent of the respondents in the current study were in their last clinical experience, but their list of stressors was similar to the students in the year 1 and 2 of the program.

Coping Strategies

Van Veld et al35 surveyed the DPT students and identified both active strategies (defined as strategies that involve proactively attempting to remove the stressful stimulus by altering habits or seeking support with the intent of receiving help) and avoidant strategies (strategies that involve using distractions to ignore the stressful stimulus). The authors identified 5 themes describing the active coping strategies used by the DPT students: exercise/health, seeking support, mindfulness, organization of tasks, and reflection. The main avoidance strategy was distraction from stressful school work. The students in the current study reported similar active strategies of exercise, relationship support, and mindfulness activities. In the study of Van Veld,35 first-year DPT students used distraction more and the active coping strategies less than the second- and third-year students, suggesting that coping self-efficacy improves with progression through the program. The DPT students in the current study reported similar active and avoidance strategies, regardless of year in the program.

Other studies have also found that seeking social support is highly used by students of all levels in the physical therapy programs and considered to be important in maintaining well-being.15,17 Biro et al17 reported that PT students actually felt a decline in family and peer support from the first year in the program to the third year. In that study, a combined 36% of the students believed that they were somewhat lacking support and 15% believed that they were severely lacking support. The results of the current study confirm the importance of availability of and interaction with advisors, peers, family, and friends during the DPT programs.

The students in the current study reported good physical health behaviors. On average, they slept, ate, and exercised within the recommended guidelines.25,37 However, a number of students fell below the guidelines for exercise, above and below the guidelines for food intake, and a number of women reported drinking more alcohol than the recommended limit by the US Department of Health and Human Services Dietary Guidelines.25 Relaxation was underutilized by the DPT students despite the curricular content of relaxation and mindfulness for stress and pain relief. A 6-week mindfulness workshop completed by health science students resulted in improved measures of stress, mindfulness, and self-compassion.38 Similarly, an 8-week meditation intervention reduced blood pressure and perception of stress in PT students.39 Another 4-session intervention program including information on practices of Cognitive Behavioral Therapy and mindfulness, as well as lifestyle and study tips, improved DASS-21 scores in 42 health profession students.40 Sleep was inversely correlated with the DASS-21 scores, and the amount of aerobic and strengthening exercise was positively correlated with depression scores in the current study. These findings were consistent with previous reports of undergraduate and graduate students.20-22 The students in our program complete a series of therapeutic intervention courses as well as health promotion and wellness courses, yet they do not uniformly internalize and practice the health strategies of adequate sleep, nutrition, and exercise.

Program Response

The presence of mental health disorders affects executive function, thereby affecting academic performance and a litany of associated physical and personal implications.41 It is important that the DPT faculty advisors understand the incidence of mental health disorders in the undergraduate populations that matriculate into graduate DPT programs and the increased likelihood of additional stress developing during the DPT programs. The Doctor of Physical Therapy program retention is often discussed regarding student academic difficulties, but these results suggest that the mental health disorders could magnify the academic challenges or, in some cases, be the primary cause of student departures. The Doctor of Physical Therapy curricula must meet the accreditation standards that include educational content regarding health and wellness.42 As educators, we hope that our students not only learn the principles of population health and wellness but also apply them personally as they develop into health care providers who can model healthy physical and mental behaviors. Given the incidence of stress, anxiety, depression, and suicide ideation in our student population, our faculty felt compelled to address the student mental health in a number of ways. Matriculating students receive a letter before orientation that encourages them to continue the use of strategies that they used as undergraduates including medications, counseling, and accommodations for test taking. We have increased the time spent during orientation for reviewing the student resources including counseling, faculty advising, and peer tutoring, and emphasizing the importance of self-care in the physical, mental, relational, and emotional realms. Therapeutic exercise course content includes the evidence-based associations of exercise, sleep, and nutrition for student physical and mental health. Faculty development has included training sessions with our school counselors that emphasize signs and symptoms of mental health disorders and guidelines for advising and referring to other professionals.

Limitations

Additional studies with larger sample sizes and from various geographical regions would improve generalizability of the incidence and types of mental health disorders, perceived stressors, and coping strategies of the DPT students. A larger nationwide study of the DPT student mental health is currently being investigated by one author, and a task force has been formed by the American Council of Academic Physical Therapy to identify best practices for academic programs to support the DPT students' health.

CONCLUSIONS

Of the 59 DPT students who participated in this survey, only 46% had normal ranges for all 3 subscales of the DASS-21 and a concerning number of students scored moderate and severe levels of stress, anxiety, and depression, and one student had an extremely severe depression score. The incidence of stress, anxiety, and depression was lower than reported in some previous studies of undergraduate and graduate students; however, 7% of our respondents reported previous suicide ideation which is consistent with the undergraduate and graduate literature. Physical health behaviors such as sleep, nutrition, and exercise were used by most students, but not consistently at recommended levels. The Doctor of Physical Therapy programs are advised to consider implementation of strategies for improving physical and mental health behaviors of students.

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Keywords:

Student mental health; Student physical health; DASS

Supplemental Digital Content

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